Documentation of Glasgow Coma Scale in Motor (Broca's) Aphasia
Document the GCS using all three components (Eye-Verbal-Motor) with the actual verbal score the patient achieves, and explicitly note "motor aphasia present" in your documentation. 1, 2
Rationale for Full GCS Documentation
The GCS should always be reported by its three individual components (E-V-M) rather than solely as a summed total, as this provides more granular clinical information. 2 In patients with motor aphasia:
The verbal component remains valid and prognostically important even when dysphasia is present, as it adds independent predictive information beyond the eye and motor components for both mortality and functional recovery. 3
Motor aphasia affects language production but not consciousness level, which is what the GCS fundamentally measures. 4 The verbal score captures the patient's actual ability to produce speech, which has prognostic value regardless of whether the impairment stems from altered consciousness or focal neurological deficit. 3
The verbal score independently predicts outcome in stroke patients with dysphasia, with studies showing it provides greater prognostic value than the motor score in this population. 3
Specific Documentation Approach
Score What You Observe
Assess the verbal response based on what the patient actually produces: If the patient makes incomprehensible sounds, score V=2; if they utter inappropriate words, score V=3; if confused/disoriented, score V=4. 1, 2
Document the presence of aphasia separately in your clinical notes (e.g., "GCS 13 (E4V4M5), motor aphasia present"). 1 This clarifies that the verbal score reflects both consciousness level and focal neurological deficit.
Serial Assessments Are Critical
Repeat GCS assessments provide substantially more valuable information than single determinations, with declining scores indicating poorer prognosis. 5
Monitor every 15 minutes for the first 2 hours, then hourly for 12 hours in moderate-to-severe cases. 1, 5
A decrease of at least 2 points should trigger immediate repeat CT scanning. 1, 5
Common Pitfalls to Avoid
Do Not Use Modified Scoring Systems
Avoid eliminating the verbal component or using arbitrary substitution values (such as scoring V=1 or using median values), as these approaches have not been validated and discard prognostically important information. 6
While regression models can predict verbal scores from eye and motor components in intubated patients 7, 8, these are specifically designed for mechanical barriers to speech, not aphasia, where the patient can still attempt verbal responses.
Do Not Confuse Aphasia with Altered Consciousness
Motor aphasia represents a focal cortical deficit affecting language production, not a global depression of consciousness. 4 The patient may be fully alert (E4) with normal motor responses (M6) despite impaired verbal output.
The motor component has the highest predictive value and remains most robust even when other components are affected. 1, 5, 2
Additional Documentation Elements
Always document pupillary size and reactivity at each GCS assessment, as these are key prognostic indicators independent of the GCS score. 1, 5